DOCSLIB.ORG

Patient Assessment and Vital Signs Measurement and Documentation July 2015

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Patient Assessment and Vital Signs Measurement and Documentation July 2015 Patient Assessment and Vital Signs Measurement and Documentation July 2015 SUMMARY: Sleep technologists observe and monitor physical signs and symptoms, general behavior and physical responses and perform and document patient assessment and vital signs measurement, under the general supervision of a licensed physician to assist in the evaluation, treatment and follow-up of sleep disorders patients of all ages. The ability to perform an accurate assessment and document certain standard measures and vital signs, including height, weight, BMI, neck circumference, pulse, respiratory rate, blood pressure and body temperature are standard processes in the evaluation of sleep facility patients. KEY DEFINITIONS SLEEP FACILITY refers to any hospital-based physician practice or independent Sleep Center or Laboratory for Sleep Related Breathing Disorders. SLEEP TECHNOLOGIST refers to a trainee, technician or technologist for the purpose of this document. Note that the sleep technologist designation refers to those who have passed a credentialing examination and are identified by the Registered Sleep Technologist (RST) or Registered Polysomnographic Technologist (RPSGT) credential. 1.0 SCOPE This technical guideline will address patient assessment and measurements of height, weight, body mass index (BMI) and standard vital signs that are routinely performed as part of the technologist’s evaluation of patients with sleep disorders. 1.1 ASSESSMENT Vital signs show how well the vital organs of the body, such as the heart and lungs are working. All vital signs should be assessed when the individual is at rest. Wait 30 minutes to assess vital signs if a person has just eaten, drank a hot or cold beverage, smoked, or exercised. The following are the typical measurements and assessments performed and documented by a technologist: 1. Height 2. Weight 3. BMI 4. Neck Circumference 5. Pulse 6. Respiratory Rate 7. Blood Pressure 8. Body Temperature Prior to beginning any assessment the technologist assures equipment is clean and ready for use, washes hands, identifies the patient, introduces himself, and explains the procedure. All measurements and assessments are accurately documented in the patient’s medical record. 2.0 ASSESSMENT TECHNIQUES 2.1 MEASURING HEIGHT Height measurements are usually taken using a drop down measure attached to a scale or wall. The patient should remove their shoes, be positioned directly underneath the drop down measuring device stand straight and look directly forward. Lower the measuring device until it rests gently on the top of the head. Document the measurement. 2.2 MEASURING WEIGHT To reliably measure body weight zero the scales, have the patient remove heavy clothing and items in pockets, and stand still on the scale. Wait for the needle or digital reading to stabilize before recording the measurement. Document the measurement. 2.3 CALCULATING BODY MASS INDEX (BMI) The BMI calculation is based on comparing weight against height. BMI is easy to calculate and the results are repeatable and consistent. The equation for BMI is: BMI = Weight (kg) / Height (m)2 (Weight in kilograms divided by height in meters squared) BMI can also be calculated by dividing weight in pounds by height in inches squared and multiplying by a conversion factor (703). 2.4 MEASURING NECK CIRCUMFERENCE Use a flexible measuring tape to measure circumference in inches or centimeters. 2 For males place the tape underneath the Adam's apple to measure. To find the Adam's apple, have the patient tilt his head back and feel for a lump or protrusion. Place the tape underneath the protrusion. Measure and document circumference. For females, place the tape over the point just below your larynx. To find the larynx, gently place a few fingers on the front of the patient’s neck and ask her to swallow. You will feel a lump after the swallow. Place the tape just below that point. Measure and document circumference. 2.5 ASSESSING THE PULSE Pulse can be assessed at the radial artery (in the wrist at the base of the thumb), the carotid artery (on each side of the neck) or apically (over the heart with a stethoscope). A regular pulse rhythm is steady beat with even spacing between beats. An irregular pulse has no pattern, may have skipped beats and spacing between beats may vary. The pulse is usually strong with easy to feel beats. A weak and thready pulse is more difficult to feel and inconsistent. An irregular pulse and/or weak pulse could be a sign of a serious health concern. The pulse is generally assessed at the radial artery in the wrist using two fingers (never the thumb) to feel the artery, pressing just hard enough to feel the pulse. Count beats for 30 seconds using a watch or clock with a second hand. Double the number counted in 30 seconds. Recount if pulse is irregular. Document pulse rate, regularity and strength of beat; and report any irregularities. 2.6 ASSESSING RESPIRATORY RATE Measuring the number of breaths in one minute determines respiratory rate. Respirations may be counted by watching the number of times the chest rises and falls or by placing the hand on the chest or stomach and feeling the number of times the chest rises and falls in one minute. One respiration is equal to the chest rising (inhale) and falling (exhale) one time. Count respirations for 60 seconds using a watch or clock with a second hand. It may be helpful to pretend to continue checking the pulse while determining the respiratory rate. Patients may alter their respiratory rate if they see you are trying to obtain it. Document the respiratory rate and any abnormal findings or irregularities. 2.7 MEASURING BLOOD PRESSURE Blood pressure is affected by time of day (low at night; peak about eight hours after awakening); 3 emotions (stress increases blood pressure); weight (obesity typically increases blood pressure); activity level; excess sodium (salt) intake; excessive alcohol consumption; and use of certain drugs, including birth control pills, steroids, decongestants, and anti-inflammatory medications. A blood pressure is taken with a stethoscope and a blood pressure cuff (sphygmomanometer) or an electronic blood pressure instrument placed on the finger, wrist, or arm that displays the blood pressure (systolic and diastolic) and pulse reading digitally. Follow the manufacturer’s instructions for the proper use of digital equipment. Wipe blood pressure instrument cuffs with an approved hospital disinfectant wipe after each use. 2.7.1 Manually Measuring Blood Pressure Locate the brachial pulse one to one and a half inches above the inside of the elbow. Wrap and fasten a deflated blood pressure cuff smoothly and snuggly around the upper arm at least one inch above the elbow (point arrow or dot on cuff at brachial pulse). Place earpieces of stethoscope in your ears and diaphragm of the stethoscope over the brachial pulse, close valve on air pump (turn knob to the right to close) and pump air to inflate cuff until the dial reaches at least 170. It may be necessary to increase the pressure to a higher level if the patient’s blood pressure is higher. Slowly deflate cuff at a constant rate (turn knob to the left slowly) and watch numbers as the needle falls. Listen for the first thumping sound (systolic pressure) and the last clear thump (diastolic pressure). Deflate cuff completely and document the systolic and diastolic pressures. Report any abnormal readings. Wipe blood pressure instrument cuffs and stethoscope with an approved hospital disinfectant wipe after each use. 2.8 MEASURING TEMPERATURE Temperature may be assessed using a variety of thermometers: a glass thermometer, digital thermometer, or a tympanic (ear) thermometer. The easiest and most commonly used is a digital thermometer. Document date, time and temperature as oral (O), axillary (A), or ear (E). Example: 98.6 (O). 2.8.1 Using a Digital Thermometer Cover the thermometer with a plastic sleeve. Press the button to set the thermometer. Place the thermometer under the tongue and have the patient close his mouth and breathe through the nose for several minutes. Take the thermometer out of the individual’s mouth and read the temperature when the indicator lights. Document the instrument reading. Discard plastic sleeve after use. An axillary temperature (under the armpit with tip of the thermometer against dry skin and held in place by the arm for 5 minutes) may also be obtained using a digital thermometer. 4 2.8.2 Using a glass thermometer: Hold the thermometer by the stem and shake the thermometer down to below 96 degree. Use a plastic slip to cover the thermometer and place under the tongue. Have the patient close his mouth and breathe through the nose for at least three minutes. Remove the thermometer, remove the plastic cover and hold thermometer at eye level by the stem rotating until the line is visible. Read and document temperature. Wipe the thermometer with alcohol and rinse in warm water after use. 2.8.3 Using a tympanic thermometer: Follow manufacturer’s directions for use. Attach a disposable ear tip and insert tympanic thermometer in the ear canal. Document the instrument reading. Discard disposable ear tip after use. 3.0 DOCUMENTATION Document all values obtained in the patient’s electronic medical record in discrete value fields if possible, or in the patient’s sleep facility chart. 4.0 BMI SCALE¹ Underweight = <18.5 Normal = 18.5-24.9 Overweight = 25.0-29.9 Obese = >30.0 5.0 NORMAL RANGES FOR ADULT VITAL SIGNS² Pulse: 60 – 90 beats per minute Respirations: 12 – 28 breaths per minute Blood pressure:
Load more

Recommended publications
  • General Signs and Symptoms of Abdominal Diseases
    General signs and symptoms of abdominal diseases Dr. Förhécz Zsolt Semmelweis University 3rd Department of Internal Medicine Faculty of Medicine, 3rd Year 2018/2019 1st Semester • For descriptive purposes, the abdomen is divided by imaginary lines crossing at the umbilicus, forming the right upper, right lower, left upper, and left lower quadrants. • Another system divides the abdomen into nine sections. Terms for three of them are commonly used: epigastric, umbilical, and hypogastric, or suprapubic Common or Concerning Symptoms • Indigestion or anorexia • Nausea, vomiting, or hematemesis • Abdominal pain • Dysphagia and/or odynophagia • Change in bowel function • Constipation or diarrhea • Jaundice “How is your appetite?” • Anorexia, nausea, vomiting in many gastrointestinal disorders; and – also in pregnancy, – diabetic ketoacidosis, – adrenal insufficiency, – hypercalcemia, – uremia, – liver disease, – emotional states, – adverse drug reactions – Induced but without nausea in anorexia/ bulimia. • Anorexia is a loss or lack of appetite. • Some patients may not actually vomit but raise esophageal or gastric contents in the absence of nausea or retching, called regurgitation. – in esophageal narrowing from stricture or cancer; also with incompetent gastroesophageal sphincter • Ask about any vomitus or regurgitated material and inspect it yourself if possible!!!! – What color is it? – What does the vomitus smell like? – How much has there been? – Ask specifically if it contains any blood and try to determine how much? • Fecal odor – in small bowel obstruction – or gastrocolic fistula • Gastric juice is clear or mucoid. Small amounts of yellowish or greenish bile are common and have no special significance. • Brownish or blackish vomitus with a “coffee- grounds” appearance suggests blood altered by gastric acid.
    [Show full text]
  • Heart Failure
    Heart Failure Sandra Keavey, DHSc, PAC, DFAAPA Defined Heart failure (HF) is a common clinical syndrome resulting from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. HF may be caused by disease of the myocardium, pericardium, endocardium, heart valves, vessels, or by metabolic disorders Epidemiology-Magnitude Heart failure disproportionately affects the older population. Approximately 80% of all cases of heart failure in the United States occur in persons aged 65 years and older. In the older population, heart failure accounts for more hospital admissions than any other single condition. Following hospitalization for heart failure, nearly half are readmitted within 6 months. Epidemiology-Prevalence Prevalence. About 5.1 million people in the United States have heart failure. One in 9 deaths in 2009 included heart failure as contributing cause. About half of people who develop heart failure die within 5 years of diagnosis. 25% of all heart failure patients are re-admitted to the hospital within 30 days. 50% of all heart failure patients are re-admitted to the hospital within 6 months. Systolic vs Diastolic There are two common types of heart failure Systolic HF Systolic HF is the most common type of HF Now referred to as HFrEF Heart Failure reduced Ejection Fraction The heart is weak and enlarged. The muscle of the left ventricle loses some of its ability to contract or shorten. Diastolic HF Diastolic HF is not an isolated disorder of diastole; there are widespread abnormalities of both systolic and diastolic function that become more apparent with exercise.
    [Show full text]
  • Cardiovascular Assessment
    Cardiovascular Assessment A Home study Course Offered by Nurses Research Publications P.O. Box 480 Hayward CA 94543-0480 Office: 510-888-9070 Fax: 510-537-3434 No unauthorized duplication photocopying of this course is permitted Editor: Nurses Research 1 HOW TO USE THIS COURSE Thank you for choosing Nurses Research Publication home study for your continuing education. This course may be completed as rapidly as you desire. However there is a one-year maximum time limit. If you have downloaded this course from our website you will need to log back on to pay and complete your test. After you submit your test for grading you will be asked to complete a course evaluation and then your certificate of completion will appear on your screen for you to print and keep for your records. Satisfactory completion of the examination requires a passing score of at least 70%. No part of this course may be copied or circulated under copyright law. Instructions: 1. Read the course objectives. 2. Read and study the course. 3. Log back onto our website to pay and take the test. If you have already paid for the course you will be asked to login using the username and password you selected when you registered for the course. 4. When you are satisfied that the answers are correct click grade test. 5. Complete the evaluation. 6. Print your certificate of completion. If you have a procedural question or “nursing” question regarding the materials, call (510) 888-9070 for assistance. Only instructors or our director may answer a nursing question about the test.
    [Show full text]
  • Medical Terminology Abbreviations Medical Terminology Abbreviations
    34 MEDICAL TERMINOLOGY ABBREVIATIONS MEDICAL TERMINOLOGY ABBREVIATIONS The following list contains some of the most common abbreviations found in medical records. Please note that in medical terminology, the capitalization of letters bears significance as to the meaning of certain terms, and is often used to distinguish terms with similar acronyms. @—at A & P—anatomy and physiology ab—abortion abd—abdominal ABG—arterial blood gas a.c.—before meals ac & cl—acetest and clinitest ACLS—advanced cardiac life support AD—right ear ADL—activities of daily living ad lib—as desired adm—admission afeb—afebrile, no fever AFB—acid-fast bacillus AKA—above the knee alb—albumin alt dieb—alternate days (every other day) am—morning AMA—against medical advice amal—amalgam amb—ambulate, walk AMI—acute myocardial infarction amt—amount ANS—automatic nervous system ant—anterior AOx3—alert and oriented to person, time, and place Ap—apical AP—apical pulse approx—approximately aq—aqueous ARDS—acute respiratory distress syndrome AS—left ear ASA—aspirin asap (ASAP)—as soon as possible as tol—as tolerated ATD—admission, transfer, discharge AU—both ears Ax—axillary BE—barium enema bid—twice a day bil, bilateral—both sides BK—below knee BKA—below the knee amputation bl—blood bl wk—blood work BLS—basic life support BM—bowel movement BOW—bag of waters B/P—blood pressure bpm—beats per minute BR—bed rest MEDICAL TERMINOLOGY ABBREVIATIONS 35 BRP—bathroom privileges BS—breath sounds BSI—body substance isolation BSO—bilateral salpingo-oophorectomy BUN—blood, urea, nitrogen
    [Show full text]
  • Study Guide Medical Terminology by Thea Liza Batan About the Author
    Study Guide Medical Terminology By Thea Liza Batan About the Author Thea Liza Batan earned a Master of Science in Nursing Administration in 2007 from Xavier University in Cincinnati, Ohio. She has worked as a staff nurse, nurse instructor, and level department head. She currently works as a simulation coordinator and a free- lance writer specializing in nursing and healthcare. All terms mentioned in this text that are known to be trademarks or service marks have been appropriately capitalized. Use of a term in this text shouldn’t be regarded as affecting the validity of any trademark or service mark. Copyright © 2017 by Penn Foster, Inc. All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner. Requests for permission to make copies of any part of the work should be mailed to Copyright Permissions, Penn Foster, 925 Oak Street, Scranton, Pennsylvania 18515. Printed in the United States of America CONTENTS INSTRUCTIONS 1 READING ASSIGNMENTS 3 LESSON 1: THE FUNDAMENTALS OF MEDICAL TERMINOLOGY 5 LESSON 2: DIAGNOSIS, INTERVENTION, AND HUMAN BODY TERMS 28 LESSON 3: MUSCULOSKELETAL, CIRCULATORY, AND RESPIRATORY SYSTEM TERMS 44 LESSON 4: DIGESTIVE, URINARY, AND REPRODUCTIVE SYSTEM TERMS 69 LESSON 5: INTEGUMENTARY, NERVOUS, AND ENDOCRINE S YSTEM TERMS 96 SELF-CHECK ANSWERS 134 © PENN FOSTER, INC. 2017 MEDICAL TERMINOLOGY PAGE III Contents INSTRUCTIONS INTRODUCTION Welcome to your course on medical terminology. You’re taking this course because you’re most likely interested in pursuing a health and science career, which entails ­proficiency­in­communicating­with­healthcare­professionals­such­as­physicians,­nurses,­ or dentists.
    [Show full text]
  • Signs and Symptoms
    Signs and Symptoms Some abnormal heart rhythms can happen without the person knowing it, while some may cause a feeling of the heart “racing,” lightheadedness, or dizziness. At some point in life, many adults Rapid Heartbeat – Tachycardia have had short-lived heart rhythm When the heart beats too quickly changes that are not serious. (usually above 100 beats per minute), the lower chambers, or Certain heart rhythms, especially ventricles, do not have enough time those that last long enough to af - to fill with blood, so they cannot ef - fect the heart’s function, can be fectively pump blood to the rest of serious or even deadly. the body. When this happens, some Palpitation or Skipped Beat people have symptoms such as: Although it may seem as if the Skipping a beat Slow Heartbeat – Bradycardia heart missed a beat, it has really had an early heartbeat — an extra If the heartbeat is too slow (usually Beating out of rhythm below 60 beats per minute), not beat that happens before the heart Palpitations has a chance to fill with blood. enough blood carrying oxygen Fast or racing heartbeat Therefore the squeeze is empty flows through the body. The symptoms of a slow heartbeat are: and results in a pause. Shortness of breath Fatigue (feeling tired) Fluttering Chest pain A fluttering sensation (like butter - Dizziness Dizziness flies in the chest) is usually due to Lightheadedness extra or “skipped beats” that occur Lightheadedness Fainting or near fainting one right after the other, or may be Fainting or near fainting caused by other kinds of abnormal heart rhythms.
    [Show full text]
  • Arrhythmia What Is It?
    Arrhythmia What is it? Most of us have felt our heart race or skip a beat. It’s fairly normal every once and a while. But for some people, it’s a sign of arrhythmia – a disorder of your heart rate or rhythm – that needs to be checked out by a specialist. If you have an arrhythmia (there are multiple types), your heart either beats: • too fast • too slow or • with an irregular pattern Did You Know? This change in your heart rhythm is usually caused by a “glitch” Our heart beats an average of in your heart’s electrical activity, which tells the heart when to 70 to 80 times a minute and contract and pump blood to the body. Your heart doesn’t beat over 100,000 times a day! It’s with the regularity of a Swiss watch, and many factors can cause no wonder millions of people an irregularity. notice palpitations such as skipping a beat, fluttering or a Some of these factors include: racing heart. • having had a heart attack • having heart failure • blood chemistry imbalances • abnormal hormone levels • alcohol, caffeine and other substances or medicines • a variety of inherited abnormalities 8 Tips for Staying Heart Healthy with Arrhythmias Living with an arrhythmia varies tremendously from one person to the next. It will depend on the type of arrhythmia you have, how serious it is and the recommended treatment. Some people can take a single medication to correct their heart’s rhythm; others undergo electrophysiology studies or require a pacemaker or implantable defibrillator. No matter what kind of arrhythmia you have, there are things you can do to keep your heart healthy and ticking as it should.
    [Show full text]
  • The Accuracy of Alternatives to Mercury Sphygmomanometers OCTOBER 2009
    HEALTH CARE RESEARCH COLLABORATIVE The Accuracy of Alternatives to Mercury Sphygmomanometers OCTOBER 2009 A U T H O R : Susan Buchanan, MD, MPH Health Care Without Harm has initiated a research collaborative coordinated by faculty of the University of Illinois at Chicago School of Public Health, with support from the Pioneer Portfolio of the Robert Wood Johnson Foundation, aimed at stimulating collaborative research around health and safety improvements in health care. This collaborative is designed to increase the evidence base concerning the human health and environmental impacts of materials, products and practices within health care. In partnership with the Global Health and Safety Initiative (GHSI), the Research Collaborative is engaged in research directed at the intersection of environmental, patient, and worker safety issues related to building and operating health care institutions. This paper is the third in a series of papers in which the Collaborative provides research and analysis of factors influencing patient, worker and environmental safety and sustainability in the healthcare sector. The editors of this series are Peter Orris, MD, MPH and Susan Kaplan, JD. TABLE OF CONTENTS Executive Summary .......................................................................................................................................3 I. Introduction .........................................................................................................................................4 II. Methods ...............................................................................................................................................7
    [Show full text]
  • Who Technical Specifications for Automated Non-Invasive Blood Pressure Measuring Devices with Cuff
    WHO TECHNICAL SPECIFICATIONS FOR AUTOMATED NON-INVASIVE BLOOD PRESSURE MEASURING DEVICES WITH CUFF WHO MEDICAL DEVICE TECHNICAL SERIES fully automated cuff 01 WHO TECHNICAL SPECIFICATIONS FOR AUTOMATED NON-INVASIVE BLOOD PRESSURE MEASURING DEVICES WITH CUFF WHO MEDICAL DEVICE TECHNICAL SERIES WHO technical specifications for automated non-invasive blood pressure measuring devices with cuff ISBN 978-92-4-000265-4 (electronic version) ISBN 978-92-4-000266-1 (print version) © World Health Organization 2020 Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. WHO technical specifications for automated non-invasive blood pressure measuring devices with cuff. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.
    [Show full text]
  • GE Reflux Presentations, Complications, and Treatment
    GE Reflux Presentations, Complications, and Treatment Osama Almadhoun, MD Chief, UBMD Pediatric Gastroenterology Associate Professor, University at Buffalo Learning Objectives • Understand the difference between GER and GERD • To review the signs and symptoms related to GERD • Discuss the diagnostic and therapeutic management of GER. • Learn about indications and potential complications of Fundoplication. • Understand literature and management dilemmas for Extra- Esophageal manifestations of GER(D) GER • Passage of gastric contents into the esophagus. – Normal physiologic process, last <3 minutes. – Occur in the postprandial period and cause few or no symptoms. • Normal COMMON!!!phase in the development in infants and toddlers – 50% of infants in the first 3 mos of life – 67% of 4 month old infants – 5% of 10 to 12 month old infants. • Happy “Spitters” • No evaluation or testing is necessary Nelson et al, 1997 GERD GERD is present when the reflux of gastric contents causes troublesome symptoms and/or complications. Refractory GERD . GERD not responding to optimal treatment after 8 weeks. Regurgitation: The passage of refluxed gastric contents into the oral pharynx. Vomiting: Expulsion of the refluxed gastric contents from the mouth. Proportion (%) of children who spilled. A James Martin et al. Pediatrics 2002;109:1061-1067 Reflux Mechanism Intragastric pressure overcomes the opposition of the high- pressure zone at the distal end of the esophagus: • LES tone • Diaphragmatic crura • Intraabdominal portion of the esophagus • Angle of His Dent J et al, J Clin Invest, 1980 Mittal, R. K. et al. N Engl J Med 1997;336:924-932 Pathogenesis • Primary Mechanism • Transient lower esophageal sphincter relaxations (TLESRs) • Decrease basal LES tone GER and impaired esophageal acid clearance • Secondary Mechanism • Overfeeding, Overweight • Increased intra-abdominal pressure • Delayed Gastric Emptying • There are a number of challenges to defining GER and GERD in the pediatric population.
    [Show full text]
  • Module 10: Vital Signs
    Module 10: Vital Signs Module 10: Vital Signs Minimum Number of Theory Hours: 3 Recommended Clinical Hours: 6 Statement of Purpose: The purpose of this unit is to prepare students to know how, when and why vital signs are taken and how to report and chart these procedures. Students will learn the correct procedure for measuring temperature, pulse, respirations, and blood pressure. They will learn to recognize and report normal and abnormal findings. Terminology: Temperature: Blood Pressure Pulse Respiration Pain (effects on Vital signs) 1. Afebrile 10. Aneroid manometer 22. Apical 33. Abdominal respirations 46. Acute pain 2. Axilla 11. Bell 23. Arrhythmia 34. Apnea 47. Chronic pain 3. Celsius 12. Diaphragm 24. Bounding 35. Bradypnea 4. Fahrenheit 48. Phantom pain 13. Diastolic 25. Brachial 36. Cheyne-Stokes 5. Febrile 49. Pain scales 6. Metabolism 14. Hypertension 26. Bradycardia 37. Cyanosis 7. Mucosa 15. Hypotension 27. Carotid 38. Diaphragm 8. Pyrexia 16. Orthostatic hypotension 28. Pulse deficit 39. Dyspnea 9. Tympanic 17. Pre-hypertension 29. Radial 40. Labored respiration 18. Pulse pressure 30. Rhythm 41. Orthopnea 19. Sphygmomanometer 31. Thready 42. Shallow respiration 20. Stethoscope 32. Tachycardia 43. Stertorous 21. Systolic 44. Tachypnea 45. Temperature, Pulse, Respiration (TPR) Patient, patient/resident, and client are synonymous terms Californiareferring to Community the person Colleges Chancellor’s Office Nurse Assistant Model Curriculum - Revised December 2018 Page 1 of 46 receiving care Module 10: Vital Signs Patient, resident, and client are synonymous terms referring to the person receiving care Performance Standards (Objectives): Upon completion of three (3) hours of class plus homework assignments and six (6) hours of clinical experience, the student will be able to: 1.
    [Show full text]
  • Mod. 3 Vital Signs
    Mod. 3 Vital Signs 1. What is most important to assess during secondary assessment? a. Airway b. Pulse c. Respiration d. Chief complaint 2. The first set of vital sign measurements obtained are often referred to as which of the following? a. Baseline vital signs b. Normal vital signs c. Standard vital signs d. None of the above 3. A patient with a pulse rate of 120 beats per minute is considered which of the following? a. Dyscardic b. Normocardic c. Tachycardic d. Bradycardic 4. Where do baseline vital signs fit into the sequence of patient assessment? a. Ongoing assessment b. At primary assessment c. At secondary assessment d. At the patient's side 5. In a conscious adult patient, which of the following pulses should be assessed initially? a. Brachial b. Radial c. Carotid d. Pedal 6. You are assessing a 55-year-old male complaining of chest pain and have determined that his radial pulse is barely palpable. You also determine that there were 20 pulsations over a span of 30 seconds. Based on this, how would you report this patient's pulse? a. Pulse 20, weak, and regular b. Pulse 20 and weak c. Pulse 40 and weak d. Pulse 40, weak, and irregular 7. Which of the following are the vital signs that need to be recorded? a. Pulse, respiration, skin color, skin temperature and condition b. Pulse, respiration, skin color, skin temperature and condition, pupils, blood pressure, and bowel sounds c. Pulse, respiration, skin color, skin temperature and condition, pupils, and blood pressure d. Pulse, respiration, skin color, skin temperature, pupils, and blood pressure 8.
    [Show full text]